Leader Registration Form

Leader Type

Adult 18+

Junior 16-17

Personal Information

First Name

Last Name

Phone Number

Home Address

Country/Region

Address

City

Zip / Postal code

Gender at Birth

Male

Female

Date of Birth

Month

Day

Year

Age

I understand that by filling out this registration form, I give my permission for my background check to be ran and agree to complete the Child Abuse training that are both required every two years.

T-Shirt Size

I would like to pre-order a T-shirt for $20

I would like to pre-order a refillable water bottle for $15

Background Information

Child Abuse or Sexual Molestation Conviction

Yes

Have you ever been convicted of (or pleaded guilty to) child abuse or a crime involving actual or attempted sexual molestation of a minor or adult?

Other Criminal Convictions

Yes

Have you ever been convicted of or pleaded guilty to any other crimes?

Special Certifications

Do you have any special certifications? Please list them here.

Medical Information

Chronic/Recurring Conditions

Please list any chronic/recurring conditions (optional)

Activity Restrictions

Yes

Are activities restricted?

Food Allergies

Yes

Does this registrant have any food allergies?

Other Allergies

Yes

Does this registrant have any other allergies?

Physical Disabilities or Limitations

Please list physical disabilities or limitations

Current Medications

Please list current medications

Medication Needed During Camp

Yes

Current medication needed during camp?

Tylenol Permission

Yes

May be given Tylenol?

Benadryl Permission

Yes

May be given Benadryl?

Ibuprofen Permission

Yes

May be given Ibuprofen?

Over-the-Counter Medication Permission

Yes

Leader may be given over the counter, non-prescription medications or applications, not to exceed the recommended dosage for stomach discomfort, burns, cuts, insect bites, rash or scrapes.

Emergency Contact

Contact First Name

Contact Last Name

Contact Mobile Phone

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